History of the Pediatric Patient
Introduction: common courtesies-e.g. find out how the child likes to be addressed, spend a few minutes to socialize with family.
The interview:
Age of the patient affects interview style=
Under age 5, most information will be observational and from parent/guardian
Sensitive issues may be avoided with toddler present
Age 5 & over, the child can add greatly to history-you may want to interview child alone based on C.C.
Age 11 & over, be sure to include separate time from communication alone with the patient
Identify the parents’ occupation, names, ages, if guardian-nature of relationship.
Chief complaint: If over 5 include the child’s version of the problem, distinguish concerns of patient vs parent(s), remember chief complaint may not be reason for visit.
Present Illness: Open ended questions followed by clarification, include family members’ reactions, anyone around the child with similar illness.
Birth History: review hospital records if available.
Prenatal: maternal health before and during pregnancy, illnesses caused by pregnancy, maternal weight gain, medications taken, duration of gestation, parental attitude towards pregnancy, any consanguinity of parents.
Natal: course of labor and delivery, complications, method of delivery, birth weight, birth order and current status of previous children(abortions/miscarriages).
Neonatal: apgar, gestational age, problems with feeding, complications of newborn period.
Feeding:
Infancy=breast or formula; frequency or duration, difficulties, weaning, vitamins & supplements, solid foods(introduction of table food).
Childhood=likes and dislikes-favorites.
Growth and development History:
Physical growth, psychomotor, behavior, intellectual retardation
Physical Growth: weight and height at birth and at ages 1,2,5, & 10. Age at onset of puberty, any history of slow or rapid growth, tooth eruption and loss pattern.
Developmental milestones:
Major gross motor:
Head up in prone position 1-4 months
Transfers objects from hand to hand 5-7 months
Sits without support >30 seconds 5-8 months
Cruises or walks holding on 7-13 months
Stands alone 9-15 months
Walks alone 8-15 months
Major fine motor:
Grasp 2-4 months
Reach 3-5 months
Transfers objects from hand to hand 5-7 months
Fine pincer grasp with index finger and
thumb apposition 9-14 months
Spontaneous scribbling 12-24 months
Major language/social:
Social smile 2 months
Babbles 6 months
Dad/Mama nonspecific 8 months
First word 11-12 months
Combines two words 21-24 months
Plurals 36 months
Helpful milestones after age 2: Plurals (36 months); Dressed without help (pedals on tricycle)
Social development: sleep, toliet (training), speech, habits, discipline techniques, schooling, sexuality, personality.
Childhood illness: recent exposures & illnesses since last visit.
Accidents and Injuries:
Childhood:
Current Health Status
Allergies: asthma, eczema, allergic rhinitis, insect hypersensitivity, food intolerance.
Immunizations: previous reactions
Medicines:
Screening procedures:
Social history: education and occupation of parents/guardian, emotional health and family background, parental work schedules, family support system.
Tags: allergic rhinitis, asthma, behavior, eczema, food intolerance, insect hypersensitivity, intellectual retardation, Physical growth, psychomotor
